31 August 2007

10/10 muses on how Pride goeth before the fall, relating an embarrassing story about how the gods of medicine will bring you down for excessive cockiness. I too have paid that karmic debt, and since he started the confessional, I might as well carry on...

This was way back in residency. In fact, this occurred during the last few weeks before graduation. God damn, but I was at the top of my skills then. I could put in a central line* faster than taking a piss. I could intubate with my eyes closed. Chest tubes were such common events that I let medical students do them. I fancied myself the best at doing procedures in our entire residency program -- and not entirely without cause. I had gone the three years of doing central lines on a daily basis without ever causing a single pneumothorax**. People sought me out to do the difficult procedures. One attending wrote on my evaluation, "Dr Shadowfax is almost as good as he thinks he is."

So one day the ER was almost empty. I sat around shooting the shit with Rick***, a close friend and the chief resident in our program. He was working the acute room, and I was supposed to be supervising the interns, who were all surfing the internet. A sick old man came in by ambulance and Rick went to take care of him, so I tagged along. The patient was an emaciated fellow, semi-conscious**** and in respiratory distress. So we put him on oxygen, a breathing treatment, EKG, and Rick got the guy prepped for a central line. I leaned back against the counter, sipped my coffee and watched.

Now Rick was no slouch himself at procedures. I don't want to disparage him here. But I could not resist the temptation, nay, the sacred obligation, to issue a running commentary on Rick's technique as he attempted to put in the central line. Which is to say that I taunted him. Mercilessly. Creatively. Persistently. And the more I taunted him, the more apparent it became that Rick was just not going to be able to get that line in. Maybe it was my distracting him, or maybe it was just that the thin old man's chest heaving up and down made it really difficult to get the line in. Either way, after an extended and particularly eloquent riff on how he couldn't find his way to . . . well, I'll leave it at that rather than get too obscene . . . Rick slammed down his needle in the tray and said in irritation, "OK smart-ass, you give it a try!"

I made a big show of getting my tray ready while the radiology techs took a chest x-ray. I made sure to dispense plenty of advice to Rick about how best to line up the needles and scalpels and other elementary, condescending details. Rick just glared at me. I said, "Step aside, sonny, and I'll show you how it's done." I stepped up to the neck, found my landmarks, and in 30 seconds, the line was in. I pulled my gloves off with a flourish, and told Rick that if he had any further questions I would be happy to arrange a tutorial. Rick still just glared at me.

As I began to stride masterfully out of the room, we both noticed that the patient wasn't doing so well. His respirations were much more labored, his pulse was up, and his oxygen level was down. All of a sudden, the levity was gone and we were back to work, with a really sick patient. Of course all the docs out there know what happened, so I'll skip to the punchline: a repeat chest x-ray showed a pneumothorax. Rick suddenly had the biggest shit-eating grin on his face as he showed me the picture. "Well, doctor, you had better do something about that, hadn't you?" he said. So, faced with the deteriorating respiratory status of what was now *my* patient, I intubated him, sedated him, and put in a chest tube to relieve the pneumothorax. That is the trifecta: central line followed by intubation and chest tube.

And all the while, I had to endure Rick's insightful commentary.

Karma.

*Central Line: a procedure where you shove a needle into the neck, usually into the jugular vein, and thread a catheter into or near the right atrium of the heart. Reserved for the sickest patients or those with no other veins to access.

** Pneumothorax: a rare but known complication of central line insertion in which the needle goes too far into the neck and punctures the apex of the lung. This causes the affected lung to collapse, worsens breathing (duh) and requires insertion of a chest tube -- a tube into the chest -- which re-expands the collapsed lung.

*** We're still friends, surprisingly.

**** Obligatory disclaimer: the patient was really out of it. Even I am not so unprofessional as to talk smack about another doc in front of a patient or family.

30 August 2007

It's been a tough summer for elected republicans in public restrooms. I won't bother to comment any further on Republican family-values anti-gay Senator Larry Craig's guilty plea to lewd behavior in an airport bathroom, because, really, what needs to be said about it? It's tragic and yet at the same time so very very awesome. Tragically awesome. My cup runneth over wth schadenfreude. This is even better than when Republican family-values Senator David Vitter publicly admitted the repeated use of prostitutes.

Which brings us to an interesting contrast. On the surface, the cases are similar: both Senators admitted to crimes of a sexual nature, both reek of hypocrisy, but there is one key difference. Senator Craig has been stripped of his committee positions and is under increasing pressure from the party leadership and prominent republicans to resign from the Senate. Whereas Vitter, whose confirmed transgressions go a lot further than Craigs's, not only retained his seniority and positions, but was actuallydefended by his senate colleagues and conservative pundits -- the same ones who are now demanding Craig's resignation.

What gives? Is it because there's something more creepy about getting an anonymous blowjob than paying someone to dress you up in diapers? Is it because Craig did it with men, but Vitter with women? Or is it a simple political calculation:If Craig resigns, his replacement will be appointed by a Republican governor. If Vitter were to resign, his replacement would be appointed by a Democratic governor.

In our group we are mulling over the thorny question of: what constitutes professional attire in the ED?

Some of our docs, mostly the "old school" really prefer a shirt and tie, some with a white coat.Some go more for business casual -- khakis and a collared shirt, no tie.Some are hard-core scrubs guys.

There's no "right" answer. Administrators (who generally wear suits to work) tend to prefer the formal white coat and tie look. They think that patients will be more impressed/satisfied with a formally dressed doc (research suggests otherwise). And ties can be vectors of infection. And a white coat only looks professional when it is clean and pressed -- and I am incapable of wearing a lab coat for more than five minutes before it looks so rumpled you would think I slept in it. I like scrubs -- I joke that I chose this specialty because I would get to wear my jammies to work. Patients seem understanding of the scrubs-in-the-ER thing, too.

I try to look a bit more professional by wearing dress slacks/khakis with a scrub top. Also I like the pockets.

22 August 2007

Damn. You all really are going to think I am a single payer advocate, when I wind up defending it from the absurd conservative attacks out there. But I just can't help myself restrain the impulse to rebut the rampant stupidity and disingenuous arguments out there. Kevin approvingly links to the Atlantic's new blogger, Megan McArdle and her argument that a single payer system is immoral.

So, Megan, I "get" the distinction you are making between efficiency and morality. And you're still wrong. As Bucky Katt said, you are so wrong philosophers weep at the sound of your voice.

Her argument is well summarized thusly in her words (combined from both of her posts):This isn't really insurance we're arguing about; insurance is voluntary. What we're really talking about is a tax. Single payer advocates are looking for the most politically palatable way to tax the young and healthy in order to pay for the health care of the old and sick. [...] A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick. It does not distinguish much more finely than that between the deserving and undeserving within that class. [...] What we need to know is whether the class of old and sick people as a whole are much more deserving than the class of young and healthy people; whether our transfers do more good than harm. [...] Are the old and sick needier than the young and healthy? No they are not. They have more assets and less poverty than any other group. [...] Are the old and sick unluckier than the young and healthy? Considering people as beings with duration in both time and space, no they are not. The overwhelming majority of old and sick people were once young and healthy. They got to be young and healthy, and old and sick.

I think this fairly encompasses the heart of her argument, and the bulk of her errors.

Most egregious is her complete inability to understand (or willful distortion of) the fact that health insurance is just that: INSURANCE. The goal of insurance to minimize risk by spreading the risk out among a large population. She attempts, wrongly, to recast the debate as simply that of wealth transfer, and arbitrarily defines the transfer as from the young to the old.

She seems to base her rejection of the risk pooling model on the unsupported statement that "Insurance is voluntary. This is a tax." What crap. Insurance can be, and in many cases is, compulsory. Automobile insurance is required in most states. In my locale, professional liability insurance is required of physicians. Are these also then taxes? The fact that is it required in no wise changes the nature of the program nor invalidates the concept of risk pooling.

Then, having redefined mandatory insurance as a liberal plot to transfer money from one class to another she defines the supposed beneficiary demographic as: old people. Damn old people, always wearing hats and driving slow in the left lane and bursting into congressional hearings and forcing Tom Delay to pay for their lisinopril! Easy to scapegoat, I suppose, but it's a specious association. Sure, there is a transfer of money from all premium-payers to those who sustain losses; that's how insurance works. I pay USAA my auto premium and it goes to someone who gets in an accident. In the case of health insurance, the assets are transferred from the healthy to the sick. It is, however, inaccurate to conflate that with the young and the old. Sure, young people are on the whole healthier than old people. But why not portray this as a transfer from men to women (women have significantly higher utilization of health care? Or from white to minorities (who have disproportionate rates of chronic illness)? Or from the wealthy (who tend to be healthier) to the poor? The demographics associated with illness are only poor and partial approximations of the actual target demographic: the sick.

Which leads us to Ms McArdle's next logical error: the failure to understand the concept of risk. By conflating youth with health and age with illness, she creates a sense of inevitability to illness which would, if that were quite true, lend some support to her follow-up arguments. But she conveniently neglects the fact that there are large numbers of young people who are sick and old people who are healthy. That's the reason we buy insurance: we don't know in advance whether we are going to get sick. Sure, we'll all die eventually. But morbidity and mortality are not completely parallel. I am going to die, but I probably will never need a kidney transplant. Or maybe I will be on dialysis for three decades and get two transplants which fail. Or maybe I'll ski off a cliff and be killed instantly. No way to know in advance what my fate will be (other than the grave promised to us all), so there is risk.

There's not much left to her argument once the above points have been established. But let's pick off the straggling errors, while we're at it, just for the sake of completeness. The other point she seems to not get is risk pooling. She implies that old and sick people, the perfidious parasites sucking off the teat of the virtuous and productive young, fail the 'moral test' of neediness. Old people are rich, right? For the sake of argument I'll buy the tenuous notion that old people are on average wealthier than young people, since it is entirely irrelevant! The reason we pool our risk is that when you become ill, the expense is far beyond what any one individual can bear (regardless of age). A week's stay in the ICU is a staggering cost. Dialysis, bypasses, chemotherapy, any large-scale surgery -- any of these things is beyond the financial capacity of anyone this side of William McGuire. With modern health costs, any ill person (regardless of age) is needy beyond the means of private payment.

And finally, she cannot resist, like the moth to the flame, the conservative tendency to blame the ill for their illness. I'll give her credit, though, she backs off of that point a bit, and at least does not use it as the entire foundation of her argument. And she also concedes that national health insurance just might be preferable to allowing poor people to die by the side of the road. So she's got that in her favor, and I will go on the record as saying she's not evil (as she accuses liberals of labeling her). Not evil, just terribly terribly misguided and profoundly wrong.

21 August 2007

In response to my last post, The House Whisperer asks:How do you reconcile this with your enthusiasm for single payer?

I am glad you asked. I would not, in fact, characterize myself as a single-payer enthusiast. This touches on a pet peeve of mine; in the medical blogosphere, there is this false dichotomy presented when health finance reform is discussed: either you are for single-payer, or you are against reform. There are literally dozens of proposals out there, none of which ential centralized planning or government-provided healthcare, and only one, "Medicare for all" is single payer. Medicare for all, championed by Democratic Congressman John Conyers, is not endorsed by any of the leading democratic presidential contenders. Yet there is this reactionary tendency of many in medicine and the med-bloggers to equate any fundamental health finance reform with their bete noir, socialized medicine. It's just not so.

I am an advocate for reform, and a passionate advocate for universal coverage. I am not exactly opposed to single-payer, but I am wary of it and think there are better possibilities.

So, to answer your question a little more directly, this move by Medicare to unilaterally impose "quality" rules/cost containment is a perfect example of the danger of a single-payer system. Where there is only one buyer of services, a monopsony (the inverse of monopoly), there will inevitably be downward pressure on the price of such services. As a provider (and consumer) of health care, that worries me. Medicare currently does not reimburse adequately for services provided to beneficiaries; further cuts will threaten the industry's ability to recruit talented providers and to invest in the technological infrastructure required to deliver high-quality health care.

As I have written before, a single-payer system like Medicare for all has a significant up-side. It would be more efficient in reducing administrative overhead (on both the payer and provider sides) and that efficiency would, at least temporarily, mitigate the escalation in health care costs. It would be universal, funded by premiums, and means-tested to allow coverage for the indigent and low-income classes. It would replace the god-awful patchwork of horribly underfunded programs for the poor that we currently have. It would still rely on private delivery of care by independent providers in a fee-for-service model. And it would de-burden American businesses from the cost of provideing healthcare. As a policy maker and a taxpayer, there's a lot to like there. If there were some way to insulate it from budgetary pressures, and if reimbursement were not guaranteed to go down, I could see physicians getting on board with it. But as it is, that's not likely.

20 August 2007

It's the next logical step in pay-for performance. The goal is laudable and the effect will probably be beneficial, but it is a little frustrating to view from this side of the fence. Medicare insiders will tell you quite frankly that while they (as we) view patient safely/quality of care as the highest priority and ultimate goal, these measures are being instituted with the underlying intent of cost containment. They know that any overt reductions in reimbursement will provoke a backlash from providers (including facilities), many of whom are politically well-enough connected to block it. But by linking the payment reductions to real or supposed deficiencies in quality, it creates a situation in which providers cannot oppose them without seeming to oppose patient safety initiatives, which is simply not tenable, politically. It's a catch-22.

And don't think that the physician reimbursements won't wind up encumbered in the same way, sooner or later.

A remarkable -- and powerful -- op-ed in yesterday's New York Times, written by seven members of the 82nd Airborne: The War as We Saw It

Money Quotes:

VIEWED from Iraq at the tail end of a 15-month deployment, the political debate in Washington is indeed surreal. Counterinsurgency is, by definition, a competition between insurgents and counterinsurgents for the control and support of a population. To believe that Americans, with an occupying force that long ago outlived its reluctant welcome, can win over a recalcitrant local population and win this counterinsurgency is far-fetched. As responsible infantrymen and noncommissioned officers with the 82nd Airborne Division soon heading back home, we are skeptical of recent press coverage portraying the conflict as increasingly manageable and feel it has neglected the mounting civil, political and social unrest we see every day.Political reconciliation in Iraq will occur, but not at our insistence or in ways that meet our benchmarks. It will happen on Iraqi terms when the reality on the battlefield is congruent with that in the political sphere. There will be no magnanimous solutions that please every party the way we expect, and there will be winners and losers. The choice we have left is to decide which side we will take. Trying to please every party in the conflict — as we do now — will only ensure we are hated by all in the long run.At the same time, the most important front in the counterinsurgency, improving basic social and economic conditions, is the one on which we have failed most miserably. Two million Iraqis are in refugee camps in bordering countries. Close to two million more are internally displaced and now fill many urban slums. Cities lack regular electricity, telephone services and sanitation. “Lucky” Iraqis live in gated communities barricaded with concrete blast walls that provide them with a sense of communal claustrophobia rather than any sense of security we would consider normal.In a lawless environment where men with guns rule the streets, engaging in the banalities of life has become a death-defying act. Four years into our occupation, we have failed on every promise, while we have substituted Baath Party tyranny with a tyranny of Islamist, militia and criminal violence. When the primary preoccupation of average Iraqis is when and how they are likely to be killed, we can hardly feel smug as we hand out care packages. As an Iraqi man told us a few days ago with deep resignation, “We need security, not free food.”

09 August 2007

money quote:Moments after Bonds crossed home plate into the loving arms of his family and the eventual judgment of history, he addressed the fans, thanking them for their support on his long, hard road of perverting baseball.

"Thank you very much. I got to thank all of you, all the fans here in San Francisco. It's been fantastic," he said to his deluded and complicit home crowd as his godfather Willie Mays, a fading symbol of what baseball once was, stood at his side.

As soon as Bonds completed his self-congratulation, a self-conscious gasp could be heard as a videotaped message from Hank Aaron was played over the video screen, sending surprise and a fleeting moment of uncomfortable self-awareness through both the crowd and Bonds himself.

"Throughout the past century, the home run has held a special place in baseball and I have been privileged to hold this record for 33 of those years," said Aaron, whose legacy of persevering with profound personal dignity through racism and persecution to become the all-time home run leader will hopefully not be tarnished by public acknowledgment of Bonds.

"I move over now and offer my best wishes to Barry and his family on this historic achievement," Aaron concluded, displaying infinitely more grace than Bonds, baseball fans, and perhaps even baseball itself had any right to ask of him.

06 August 2007

Ravenclaw students tend to be clever, witty, intelligent, and knowledgeable. Notable residents include Cho Chang and Padma Patil (objects of Harry and Ron's affections), and Luna Lovegood (daughter of The Quibbler magazine's editor).

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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